CLINICAL GOVERNANCE COMMITTEE ASSURANCE REPORT 21 September 2016 NHS Highland Board 29 November 2016 Item 5.3 Committee Members: In Attendance: Ms Sarah Wedgwood, Chair Ms Valerie Barker, Public Member Ms Elspeth Caithness, Staffside Representative Dr Andrew Evennett, Chair of Area Clinical Forum Dr Michael Hall, Associate Medical Director, Argyll and Bute (videoconference) Dr Rod Harvey, Board Medical Director Ms Heidi May, Nurse and Midwifery Director Dr Ken McDonald, Associate Medical Director, Raigmore Hospital Mr Alexander Murray, Public Member Dr Ian Rudd, Head of Pharmacy Prof Hugo Van Woerden, Director of Public Health Ms Myra Duncan, Non-Executive Board Director Ms Mirian Morrison, Clinical Governance Development Manager Ms Maryanne Gillies, Senior Quality Improvement Lead (Patient Safety) Ms Claire Wood, Associate Director, AHPs Ms Susan Russel, Principal Officer (Nursing), Highland Council Ms Jane Smith, Pharmacist, Medicines Management and Information Dr Susan Vaughan, Epidemiologist Ms Alison Hudson, Lead Nurse, North and West Operational Unit Mr Michael Bell, Clinical Governance Facilitator Ms Janet Spence, Head of Care Services Improvement Ms Fiona Campbell, Clinical Governance Manager (videoconference) Ms Fiona MacBain, Committee Administrator, Highland Council 1. Apologies Apologies were received from Mr Mike Evans, Non- Executive Director, Dr Stewart MacPherson, Clinical Director, South & Mid Operational Unit, Ms Gill MacVicar, Director of Operations (North and West), and Dr Michael Foxley, Non-Executive Director.
1.1 Declaration of Interest Dr Evennett declared a potential conflict of interest in the SAER report on the Nairn A&E closure detailed in Item 4.2. 2. Assurance Report and Action Plan of 28 June 2016 Mr A Murray had been wrongly named as Mr A Walker and this would be corrected. Reports from an SPSO Complaint relating to death from hepatocellular carcinoma and an SAER from a similar case were to be considered jointly if possible. There was no case study on the agenda for the second time and the Chair sought assurance there would be one on the next agenda. Clinical prioritisation of requests to the Asset Management Group. Unified coding system The investigation was still ongoing. The SAER from a South and Mid mental health case, which had also involved North and West, was to be used as a case study for the meeting in Dec 2016, to highlight the potential failures of non-standardisation of process. MM informed the Committee of a web page that was being developed to promote shared learning and facilitate sharing experiences. An icon would be added to the intranet front page once the webpage had been populated. This was an ongoing issues and had been included on the clinical risk register. This would be covered under the agenda item on HSMR. It was included on the dashboard. Mirian Morrison and Ken MacDonald to continue to monitor. Case Study added to Dec 2016 agenda. Invite Dr James Finlayson to the meeting to present the case study Mirian Morrison 3. Matters Arising These were included in other reports. 2
4.1 Argyll and Bute Exception Report Issues from the HSCP Clinical and Care Governance Committee on 23 August 2016 were included in the update. Attention was drawn to the SAERs and complaints detailed in the report. Complaint procedure was not compliant with the 20-day response target. Arising from an SAER, the increasing demand for category A mattresses was highlighted. In relation to mortality and HSMR, Lorn and the Isles Hospital was undertaking a review of documentation. In relation to SPSP, not all reports were being received. Training The Chair summarised the purpose of exception reporting and how the Committee would decide what issues to bring to the attention to the Board. An RPIW on this was due to take place starting on 31 October 2016. The approach to the provision of mattresses was being revised. A more informative manner of presenting information in this regard was being sought. Consideration was being given to the creation of a group to cover SPSP under different strands. The programme to bring all staff up to date with training was underway with a target completion date of 31 October 2016. Integrated moving and handling training was being considered for social work and health staff. The exception report offered the opportunity to share learning and experience with colleagues across Highland. Fiona Campbell highlighted types of SAERs and the actions arising from them. Mike Hall added that some SAERs were clinically specific, whereas some were of wider interest, such as the grade of radiographer able to sign off reports, which had developed into a Board-wide policy. In relation to responsibility for Board-wide policies, Heidi May confirmed that her post retained Board-wide professional accountability for their implementation. 3
The national VTE bundle for pregnant women was due to be rolled out across NHS Highland. In relation to Care at Home, it was important to ensure the correct equipment was provided. The incident which had resulted in the matter being considered was being reviewed and was not yet closed off due to its complexity. The Chair sought information on the system for ensuring SAERs were fully closed off and learning was implemented. This would be considered further under incident handling. Assurance was given that every effort was made to ensure correct equipment was provided efficiently. In the incident in question, the patient had deteriorated rapidly and there had been a fine balance between installing the equipment and not interfering with the process of care. The actions from the SAER in question be taken to the neonatal and maternity services strategy and coordination committee Fiona Campbell/Heidi May 4.2 South and Mid Exception Report and minutes of 8 September 2016 Dr A Evennett declared a potential conflict of interest in this item in part due to his intimate knowledge of the situation. The Chair expressed concern at the brevity of the exception report. Concern was expressed at the lack of detail in relation to the closure of Nairn A&E on 25 December 2014 (item 4.3 of the minute), which had been the subject of a 21 month investigation and remained unresolved. The use of an SAER to address the problem was considered inappropriate. There had been differences of opinion between management and clinicians. The committee discussed the situation and whether it was an operational matter or whether Board involvement was required. A more comprehensive report to be provided in future Stewart MacPherson Rod Harvey and Heidi May would discuss the situation with Andrew Evennett and the operational unit then decide a plan of action. 4.3 North and West Exception Report and minutes of 6 July 2016 4
Interviews would take place for a Clinical Director on 12 October 2016. The timing of QPS meetings was not ideal to meet the Clinical Governance Committee timetable. SAERs The Chair pointed out that the high number of apologies for QPS meeting was unacceptable. Increase in Grade 3 and 4 pressure ulcers since April 2016. Falls reduction improvement works continued but remained a challenge in patients with dementia. 4.4 Raigmore Hospital Five SAERs had been ratified and action owners would be asked to report back and outcomes fed into exception report. The process for dealing with pressure ulcers while under the care of the District Nurse required consideration. Use of a different improvement methodology was bringing results. With regard to the closure of the Queen Elizabeth Ward, this was because it was not considered fit for purpose. Staff would be moved along with patients. Existing staff in new wards were fully trained for falls. Heidi May summarised some of the workstreams that were in place and that they formed part of OPAH (Older People in Acute Hospitals) for which regular updates were provided to the Committee. Fiona MacBain to inform all QPS contacts of CGC dates for 2017 once approved by the Board on 27 Sept and to bring the matter to the Board Secretary s attention (done). The importance of prioritising attendance at QPS meetings should be emphasised to all who required to attend. Heidi May would take this to the Lead Nurses Group. An update on OPAH to be provided in December 2016 (added to agenda). Timetabling of QPS meetings 5 Clinical Governance meeting timetable
to be provided to QPS admins once agreed by Board (done). Ken MacDonald summarised two SAERs, one of which related to two patients who had delayed endoscopic surveillance and subsequent development of malignancy, and the other involved erroneous diagnosis of bowel cancer due to laboratory cross contamination of pathology specimen. SPSO complaints There was a variable response and turnaround rate for complaints and Falls with harm were improving in the medium to long term although medical falls remained static in terms of actual numbers of falls. HSMR The actions being taken were detailed in the report, and included eight actions focussed on capacity and process within endoscopy, a review of the endoscopy waiting list, the endoscopy service to direct pathology reports to the endoscopist undertaking the procedure, and a requirement to correlate all relevant clinical information before arriving at a diagnosis. Actions relevant to other site were being addressed by the NHSH clinical lead for endoscopy. To be covered by Mirian Morrison in her report. this was being monitored on a monthly basis by the QPS committee on a divisional basis. Clinical governance have now provided a detailed breakdown of complaints which were past the 20- day target to allow more focussed action. The Chair asked about the correlation between medication and falls. A narrative was provided for every fall with harm and this would include medication if that was an aspect of the fall. Ian Rudd suggested that this could be looked at thematically. In terms of process, the ward pharmacist would advise if medication was likely to increase the likelihood of a fall. Heidi May concurred that patients at risk of falling should have their medication reviewed and this formed part of the SPSP bundle that was being used in certain wards at Raigmore. Regular mortality reviews were being undertaken, with all type 2 and type 3 deaths being reported to the QPS sub-group for consideration of further action. Recently, issues relating to the optimal 6 Learning issues should be included in the correct column of the report to avoid them being missed.
management of sepsis had been brought to light by this process and were detailed. SPSP Attention was drawn to the policy for extended VTE prophylaxis which was available on the intranet and complied with SIGN guidelines. Discussion ensued on the plan to modify IDL to make consideration of extended VTE prophylaxis a mandatory field. The current IDL was a legacy system which was due to be renewed in 6-12 months, therefore adaptations might not be possible to the existing system. The Clinical Director for ehealth was aware of the issue. Reference was made to a case presentation to the CGC in 2014 which had involved loss of a clinical sample en route to the pathology lab. The QPS minutes referred to a Mental Health Team Social Worker being unable to access Care First System when at Raigmore due to incompatibility between NHS and Council IT systems. The QPS minutes referred to two type three deaths that had been recorded over the preceding 12 months for which catheters had been a contributing factor. The system had been improved and was being monitored via the usual incident reporting systems. A fully electronic system would be ideal but was not possible due to cost and logistics. No further cases of lost specimens had been reported. Janet Spence pointed out that Council Social Workers could use NHS equipment at Raigmore to access Care First via the NHS intranet. It was being emphasised that the removal of catheters should be considered for every patient on a daily basis. It should be made clear to all Social Work staff who might require to access Care First while at Raigmore that they could use NHS computers. 4.5 Highland Council Children s Service Clinical Governance Group of 7 September 2016 As the meeting had been inquorate, there were no minutes. An exception report was sought (in draft if Attendance at meetings had been brought up Susan Russel to discuss future 7
necessary), even if the meeting had not taken place or was inquorate. with members of the group and a deputy system was being considered. exception reporting with Council colleagues and with Heidi May. 5. Executive Leads Reports by Exception The Chair highlighted the challenges and difficult decisions the Board will be facing in the coming years and emphasised the importance of clinical safety being at the centre of decision making. (a) Caithness Neonatal Review An update was provided by Prof Hugo Van Woerden and Dr Susan Vaughan on behalf of Dr Rod Harvey which included interim measures being taken, the establishment of a working group, the aims of the public health review and the 5 objectives, which had received input from the Chief Medical Officer. The methodology for the objectives and the case note review process were presented in detail. Next steps involved validation being sought from the Board at a development session, from the CGC and from the stakeholder advisory committee, with a report on the objectives expected at the end of September 2016. Challenges for the future were also outlined. (b) National Review of Maternity and Neonatal Services Heidi May explained that there was a National Review being led by Jane Grant, CEX Forth Valley, commissioned by the Public Health Minister Maureen Watt. The Chair sought and received assurance that confidence in the methodology used was high. It was confirmed that local demographics had been taken into account. Safety was the major objective and changing practices and standards had to be taken into consideration. Once the final report had been received, it would be considered in the first instance by the Chief Executive and the Medical Director, with the decision on where to present it being dependent on the content of the report, with the Board and/or the Clinical Governance Committee being likely recipients. Much depended on the timing of the report and the requirements contained within it. It was clarified that the review was of safety and not of service reconfiguration. It was likely there would be recommendations for Clinical Governance and for Operational Units. Themes emerging included continuity of care and carer, models of maternity and neonatal care, universal pathways of care, women and families at the centre of care, removing barriers to care, developing and supporting the workforce, and key outcome measures. A national event was planned for 17 November and a report would be 8 Sonography and Maternity Services to be considered in December 2016 Helen Bryers (on agenda)
made available in due course. 6. Update on the Quality and Patient Safety Dashboard Handouts demonstrating the dashboard were provided. Measures that were not yet available for the dashboard were as follows: Radiology reporting performance was due for June 2016 but would now be available in Jan 2017. Discharge letter performance was due to be considered on 7 Oct after which a date for availability would be ascertained. Communication with primary care colleagues was an issue. It was confirmed that A&B was included in the dashboard. The Chair expressed concern at the delays and emphasised the importance of getting the dashboard operational, especially in light of the Improvement Committee no longer being in existence. Dr Evennett suggested that all Committee Chairs express their enthusiasm for the dashboard during their Board updates. Dr Harvey explained that delays were being experienced as a result of the agreed workflow for eservice planning and due to the data required being sometimes difficult to extract and in competition with date being required for government reporting. The dashboard data had not been selected for its ease of extraction but for its usefulness in improving safety. Discussion ensued on the need to include measures on pressure ulcers and falls in the dashboard as they were reported elsewhere, however the rates rather than numbers of incidents would be helpful in identifying trends. Phase 2 of the dashboard could include Council and other measures, such as those from contracted out services, however the data handling issues would be complex. The Chair offered to write to whoever necessary to speed up the implementation of the dashboard, this to be fully considered outside the meeting. The dashboard to be brought back to the Committee in Dec 2016, hopefully having been tested out (on agenda) 9
It was clarified that falls during care at home provision were reported through datix and could be drilled down to location. Clean data was essential when analysing falls, with coding being important, for example when a fall was a result of a stroke it shouldn t be counted as a fall. Similarly it was important to have data not only on the number of falls but on the number of patients falling, for example four falls could be by four different patients or the same patient falling multiple times. 7. Medication Errors Ian Rudd, Head of Pharmacy The following papers had been distributed: a. Report from the Board s Internal Auditors b. Analysis of Medication Incidents 2015-16 c. Learning from adverse events Ian Rudd sought a steer from the Committee on future reporting requirements. In response to a query from the Chair it was clarified that there was no established correlation between types of error and outcome because the medication incidents were so varied. Incidents that resulted in serious harm were rare and would be the subject of an SAER. Key to tackling medication errors was electronic prescribing and this should be highlighted to the Board. Future possibilities included a joint electronic prescribing system between community and hospitals but the implementation of hospital electronic prescribing should not be held up because of this. The Chair to highlight the importance of electronic prescribing to the Board. The Committee endorsed the approach outlined in the report to move towards collaborating with NHS Grampian with a view to introducing hospital electronic prescribing and medicines administration (HEPMA) 10
8. ehealth Portal for Highland Formulary, Medicines Policies and Junior Doctor Handbook Jane Smith, Pharmacist, Medicines Management and Information, for Ian Rudd, Head of Pharmacy Staff should to be able to find accurate, up to date information relating to medicine use easily and quickly. Patients need access to local information on access to medicines, medicines choices and their use to support self-care. To achieve this, the wide range of local policies, procedures and guidance related to therapeutics (TPPG) needed to be available electronically and in one central location. Progress was summarised and the recommendations were as follows: Work with Clinical Governance steering groups to explore ways within the Therapeutic Portal and via other route e.g. education, managerial support. Ask the Clinical Governance Committee to consider whether all TPPGs should be managed via the Therapeutic Portal. If so, then work with ehealth to investigate ways of preventing issue of TPGGS on other platforms? The steering group continue to report progress and seek advice from the ADTC every three or four months. The transparency of the proposed system was welcomed, and would be suitable for public viewing. The Committee endorsed the system development and sought a progress report in due course with any issues to be reported by exception. 9. Clinical Governance Progress Report The Chair voiced support for ensuring the recommendations in the reports were achieved. 11 Information was sought for the committee on the implications of some of the key actions arising from SAERs, as well as more detailed information on themes/issues relating to complaints about care and treatment for a future
committee Mirian Morrison 9a. Complaints including update on national procedure 9b. Scottish Public Services Ombudsman (SPSO) Report Noted current performance against the 20 working day target. Noted the cases being considered by the SPSO as of 14 September 2016. 9c. Adverse Events Noted adverse event report and major and extreme adverse events that have been reported in quarter 1. 9d. Risk Management Noted risk management arrangements and the strategic risk register. 10. Clinical Networks Prof Hugo Van Woerden Prof Van Woerden sought agreement for the direction of travel of the clinical networks and highlighted areas of particular concern. Cardiology was to be selected to address barriers to moving forward with learning then shared and spread across other networks. The Chair expressed concern that the work of the networks had fallen so far behind. It was pointed out that the networks were Raigmore-focussed, but pressure on GPS meant their attendance at scoping meetings was challenging. It was important that service redesign issues were taken into consideration. Hugo Van Woerden and Andrew Evennett would discuss the possibility of sourcing funding to aid GP participation outwith the meeting. 11. Update on SPSP programme by exception Maryanne Gillies 12
Maryanne Gillies summarised the various programmes and plans for the coming 2-3 years, as detailed in her report. Clinical governance around the SPSP involved monthly meetings of the SPSP senior leadership team. Successful projects were highlighted, such as the critical care unit having been 1000 days since the last ventilated pneumonia, which had been a common infection 6-7 years previously. Challenges included capacity and capability, and the small size of the core quality improvement team. There was a robust data management system but a significant piece of work was being done to transfer thousands of data sets from the current network drive to a web-based system and this generated some risk therefore might be worth bringing to the committee in due course. Support was being sought from Health Improvement Scotland to help create capacity to improve clinical care processes. Other areas of work that were ongoing included: urinary catheter, colorectal SSI, deteriorating patients, sepsis early recognition and treatment (for which there had been a successful bid to be one of three Boards in Scotland to spread this work to primary care and Out of Hours, for an 18- month supported collaboration), VTE work, pressure ulcers, medicine management and reconciliation, and falls. HMSR short life working group action plans were to be implemented and CGC support was sought to ensure these actions were fulfilled. Operational units were being encouraged to take a proactive approach to preventing harm. An update to be brought to the committee in around 6 months on work with ehealth to transfer data to a webbased system (added to standing items action sheet) In terms of improving capacity, three national Alison Hudson pointed out that support had been 13
courses were available that fitted with the patient safety agenda: the Fellowship which was high level, the Scottish Improvement Leaders qualification, for which applicants would be sought proactively, and the Scottish Improvement Skills qualification, which around eight people were undergoing. It would be ideal to run a similar course in Highland. Discussion ensued on the dual merits of the HQA and the SPSP and whether prioritisation required to be considered at a Board development session. provided to community hospitals, creating additional capacity. There was a national programme for reducing pressure ulcers in care homes and NHSH was part of that, with five care homes in the North and two in A&B participating. Dr Harvey explained that HQA encompassed SPSP. Lean methodology was more than RPIWS. Both methodologies were about tackling patient safety and they should not be considered to be competing. HQA was the over-arching methodology, with scope for blending with lean reliability indicators. 12. Hospital Standardised Mortality Review - Dr Rod Harvey, Medical Director Rod Harvey summarised the current position in relation to the increase in the HSMR in three hospitals. 13. Returns and Boarding Adoption of new methodology had impacted positively on Raigmore s HSMR. A meeting with Health Improvement Scotland on the matter was scheduled for the afternoon of 21 September 2016. It seemed likely that coding errors were significantly to blame for the increase in the HSMR but until this was conclusively established, safety measures were being improved with immediate effect. Senior review of coding issues was being considered, as was the quality of case note records, the use of symptomatic rather than diagnostic coding and other issues. All hospitals now had an HSMR action group. 14 Coding and record maintenance should be improved across all hospitals.
The clinical impact of regular boarding required consideration. Boarding 14. Dates of meetings for 2017 The likely clinical impact of boarding required consideration. The inclusion of data on returns on the dashboard to be considered in December 2016 Put on draft agenda for December 2016 (?) The provisional dates were noted and would be distributed once approved by the Board on 27 September 2016. The meeting ended at 12.45pm 15